NEURASTHENIA (NEURASTENIA). — Of all the terms in scientific medicine, few have enjoyed, and continue to enjoy, the fortune and diffusion of this one, introduced by the American physician Beard (1869) as an etiopathogenetic concept and synonym for “nervous exhaustion”; yet few terms have aroused a greater number of nosographic distinctions and divergences of opinion.
In the present state of knowledge, it may be held that neurasthenia, properly speaking, is a morbid form characterized by a peculiar emotion (different from anxiety), designated by the name of “alarm.” Neurasthenic alarm (Bini) is a “prevailing, unpleasant feeling of distrust and fear, signifying doubt, directed toward one’s own capacities or, more generally, toward one’s own health, often justified by psychesthesias,” that is, abnormal sensations whose erroneousness originates at a psychic level.
This syndrome of neurasthenic alarm may appear: 1) as a psychogenic reaction, that is, as an unusual, abnormal, but comprehensible manifestation appearing after events charged with emotional significance (Erlebnis), susceptible to psychic influence, and disappearing without leaving traces after removal of the causative event; 2) as innate to a type of psychopathic personality, that is, to a stably abnormal personality which, according to K. Schneider’s definition, “suffers or causes suffering”; 3) as a psychoneurotic episode, that is, as a morbid form lacking the features of a clearly psychopathic personality and in which there is no true causative event, such as occurs in psychogenic reactions. In the older descriptions of neurasthenia, distinctions were made according to the bodily region to which the disorders and their alarm reaction were referred, and thus one spoke of cerebral, spinal, sexual, gastric neurasthenia, etc. These designations rested on the pathogenetic concept of the “exhaustion of a given region of the nervous system.” With the decline of this theory, more recent specific nosographic descriptions abolish these distinctions, although in some authors a subdivision based on the predominance of somatic or psychopathic symptoms is still found: for example, K. Schneider distinguishes “somatic asthenics” from “psychic asthenics.” The term “somatopathy” includes and distinguishes: 1) the vegetative reactions of emotion (e.g., the neurasthenic who becomes absorbed in the tormenting doubt that he has heart disease, anxiously counting his pulse beats; through this emotion alone he may objectively alter them); 2) the neuroses (v.) and neurovegetative dystonias, without a conscious emotional genesis (e.g., paroxysmal tachycardia, spasmodic constipation, etc.); 3) the psychesthesias of alarm, that is, a multitude of abnormal sensations to which no objective modification corresponds. Alongside “psychesthetic-alarm neurasthenia,” which is neurasthenia properly speaking, two varieties are distinguished: “phobic-alarm neurasthenia” and “hypochondriacal neurasthenia” (in which the tenacious belief in illness is predominant).
With regard to the causality of neurasthenia, many neurasthenics attribute the onset of their disorders to events of particular emotional significance, e.g., bereavements, financial reverses, romantic disappointments, excessive work under unsatisfactory conditions, and psychic overexertion in general. Such attributions often correspond to that “need for causality,” that “post hoc ergo propter hoc,” to which the judgments of patients and family members generally succumb. These situations of affective distress are often reported and experienced in darker tones than reality warrants: the state of suffering caused by the environmental situation is more an effect than a cause of the emotional alterations, which have a fundamentally constitutional basis. A psychopathic heredity, either general or specific, is not uncommon. Neurasthenia may appear in all somatic constitutions and in all social classes, although intellectuals suffer more intensely from alarm because they are capable of a more complex elaboration of the situation. The age most affected is adulthood, with a peak between 25 and 35 years (Braun, 1935), and, in women, another peak during the climacteric period. All statistics agree in affirming that no increase in neurasthenia is observed during periods of war.
With regard to the symptomatology, the neurasthenic reacts to his disorders with characteristic behavior. The psychesthesias are initially interpreted as due to organic disease and the alarm as an appropriate emotional expression; he therefore consults the internist, not the psychiatrist. He reports his disorders with acuity and wealth of detail, often writing them down on a sheet of paper (Charcot’s “malade au petit papier”) to avoid forgetting anything. He demands special examinations, the negative results of which reassure him only briefly; the improvement following “reconstituting treatment” is slight and temporary. Distrust of the physician’s judgment sets in, and “celebrities” are sought out, with laboratory tests and medicines accumulating. Gradually, even his family members accuse him of having “fixations” and of being subject to “suggestions,” and regard him as “pusillanimous” and “lacking in willpower.” The neurasthenic reacts vigorously and harshly to these criticisms, adopting a demanding and hostile attitude. For the most part, his social and occupational activity is not seriously impaired, even though his judgment is excessively pessimistic. The impairment of intellectual work does not depend on a primary deficit in intellectual activity, but on emotional disturbance.
Objective examination reveals nothing abnormal; only in the pseudo-neurasthenic syndrome may minor signs in the vegetative sphere be observed.
In “post-traumatic” and “compensation” neuroses (v. PSYCHONEUROSES), a neurastheniform syndrome is very frequent. These are morbid forms arising after accidents or misfortunes, in which predominant etiopathogenetic importance was attributed (Oppenheim) to the physical trauma; today, by contrast, emphasis is placed on the subsequent psychic elaboration of the trauma, and the “functional” nature of the disorder is stressed. Especially in compensation psychoneuroses (“sinistros”), the importance of the trauma is entirely secondary to the injured person’s insurance situation. A subacute course lasting 4–5 months is not rare; more frequently, however, the condition lasts several years, with considerable variations in intensity.
Drug therapy is devoid of causal usefulness; it has only symptomatic value. Electroshock (v. SHOCK) may be attempted if an anxious or dysphoric component exists. Psychotherapy (v.) is the treatment of choice.